EEG appearances in acute carbamazepine toxicity.

A 16-year-old woman deliberately took a large, toxic overdose of carbamazepine and recovered despite a high plasma level. During the acute phase the EEG was dominated by occipital delta activity suggestive of a brainstem disorder. Following 24-h treatment with activated charcoal the plasma carbamazepine was cleared and the EEG returned to normal.

The effect of a high protein diet on leucine and alanine turnover in acid maltase deficiency.

Leucine and alanine production rate was measured in 5 patients with acid maltase deficiency in the postabsorptive state, following 6 months on a normal diet with placebo and 6 months on an isocaloric high protein diet (16-22% protein). Whole body leucine production rate, a measure of protein degradation, expressed in terms of lean body mass was significantly greater than in five control subjects. Following the high protein diet, leucine production rate was decreased in four of the five patients but this was not statistically significant. Alanine production rate expressed in terms of lean body mass was significantly greater than in control subjects. After the high protein diet, alanine production rate and concentration were significantly decreased (p less than 0.05). There were no significant improvements in any of the clinically relevant variables measured in these patients. It is possible that a larger increase in protein intake over a longer time period may have a clinical effect.

Instability in human forearm movements studied with feed-back-controlled muscle vibration.

1. Frequency-modulated vibration was applied to the elbow flexor and extensor tendons to produce reflex movements of the forearm in normal subjects. The modulating (command) signal caused equal and opposite deviations from the 40 Hz carrier frequency so that when flexor vibratory frequency increased, extensor frequency decreased, and vice versa. 2. It is argued that the movements resulted largely from the reflex action of muscle spindle primary afferents whose firing frequency had been 'taken over' and modulated by the vibration. 3. Bode plots relating forearm movements to command signal (modulating) frequency showed the transfer function of the Ia afferent-CNS-muscle-load system to have a low-pass filter characteristic. The phase lag of movement on command increased progressively with command signal frequency, exceeding 180 deg at 3-4 Hz. 4. The transduced forearm movements were fed back to provide the command signal to the vibrators (and thus indirectly to the spindle afferents) via a filter mimicking the dynamic responsiveness of muscle spindle primary endings. Our aim was to 'break into' the reflex arc, and re-route it so that we could artificially vary the gain without significantly altering the dynamics of the pathway. 5. Nearly all subjects developed forearm oscillations (tremor) when the gain exceeded a threshold value. Subjects varied widely in their threshold, though for a given subject the threshold remained fairly constant from day to day. The results suggest that reflexly active individuals may not have a large safety margin with respect to forearm instability. 6. The frequency range of the oscillations observed in seven subjects was 3-8 Hz. The frequencies depended upon the level of flexor-extensor co-contraction, and increased from 3 to 5 Hz at 10% co-contraction to 5-8 Hz at 100% co-contraction. An analysis of the mechanical impedance of the arm provided estimates of tremor frequencies consistent with these results. 7. These unexpectedly low tremor frequencies led us to propose that it may be erroneous to expect stretch reflexes to contribute to forearm tremor in the range 8-12 Hz (e.g. physiological and 'enhanced' physiological tremors). Rather, their contributions should be sought in the range 3-8 Hz (e.g. pathological tremors such as those of Parkinson's and cerebellar disease).

Instability in human forearm movements studied with feed-back-controlled electrical stimulation of muscles.

1. Amplitude-modulated electrical stimulation was applied to the elbow flexors and extensors to produce movements of the forearm in normal subjects. The parameters of the modulating (command) signal were set in isometric trials so as to produce equal and opposite background torques, and equal and supportive torque modulations. 2. Bode plots relating forearm movement to command signal (modulating) frequency showed the muscle-load to have a low-pass characteristic similar to that previously described in the cat, and a slightly larger bandwidth than described previously in man. 3. The transduced forearm signals were fed back to provide the command signal to the stimulators via a filter which mimicked the transfer function of muscle spindle primary endings. In effect this replaced the neural part of the reflex arc with an accessible model, but left the muscle-load effector intact. 4. All six subjects developed forearm oscillations (tremor) when the loop gain exceeded a threshold value. The mean tremor frequency at onset was 4.4 Hz, which was similar to that of the equivalent vibration-evoked tremor (previous paper, Prochazka & Trend, 1988). 5. With the linear spindle model, oscillations tended to grow rapidly in amplitude, and the stimuli became painful. The inclusion of a logarithmic limiting element resulted in stable oscillations, without significant alterations in frequency. This allowed us to study the effect on tremor of including analog delays in the loop, mimicking those associated with peripheral nerve transmission and central reflexes. In one subject, loop delays of 0, 20, 40 and 100 ms resulted in tremor at 4.0, 3.6, 3.0 and 2.1 Hz respectively, as quantified by spectral analysis. 6. By considering separately the phase contributions of the different elements of the reflex arc, including delays, it became clear that muscle-load properties were important in setting the upper limit of tremor frequencies which could conceivably be supported by reflexes. 7. The results support the conclusion of the related vibration study (Prochazka & Trend, 1988), that for moderate levels of background co-contraction, the contribution of stretch reflexes to tremor at the elbow should be sought in the 3-5 Hz range. Exaggerated long-latency reflexes would be expected to reduce these baseline frequencies by 1 or 2 Hz.

Relative displacements in muscle and tendon during human arm movements.

1. X-ray, cine and video recordings were made of the movement of radio-opaque markers injected into the musculo-tendinous junctions of biceps brachii muscle. 2. In strong isometric contractions, the distal tendon of the long head of biceps lengthened by about 2% of its estimated rest length. 3. During voluntary isotonic elbow flexion-extension movements at frequencies up to 5.5 Hz there was no detectable phase shift between intramuscular and joint displacements. 4. In the fastest alternating movements (5.5-6.7 Hz) small phase advances developed in the muscle. 5. We conclude that human tendons do stretch during muscle contraction, but not enough to cause intramuscular phase reversals in rapid unloaded movements. This in turn means that muscle spindles shorten and lengthen virtually in phase with joint movements under most conditions.

Protein turnover in acid maltase deficiency before and after treatment with a high protein diet.

A patient with acid maltase deficiency was treated with a high protein diet for 7 months. Protein turnover expressed in terms of lean body mass was shown to be increased in this patient before the diet but was markedly reduced following the diet. The patient improved clinically whilst on the diet both subjectively and in terms of mobility, breathing and reduced peripheral cyanosis at rest.

Acid maltase deficiency in adults. Diagnosis and management in five cases.

Five patients with adult onset acid maltase deficiency are described. All patients had developed their initial pelvic girdle symptoms late in the second or early in the third decade and some years later developed signs of respiratory insufficiency. Typically they were tall, had weak and wasted paraspinal and gluteal muscles with lower limb weakness. All were orthopnoeic with marked diaphragmatic weakness. In all patients characteristic glycogen vacuoles were seen in peripheral blood lymphocytes. Muscle biopsy was characteristic in only 1 out of 4 cases and showed minimal or nonspecific features in 3. The diagnosis was confirmed by enzyme assay in muscle and cultured fibroblasts. Long-term domiciliary ventilatory support (25 patient-years) using a rocking bed or intermittent positive pressure respiration with a tracheostomy has allowed a return to work in all patients, with their clinical condition remaining stable.